In my previous post I wrote about why we (including the media) should pay less attention to the pronouncements of the AMA on voluntary assisted dying, and instead look at organisations that better represent the population/s for which they speak. While there’s a general belief that the AMA represents most, or at least many, doctors, that’s far from true. Even taking that into account, however, the AMA’s stated position on behalf of its members isn’t as representative as it appears.

In 2015, the AMA (Federal) announced that it would review its policy on ‘euthanasia and doctor-assisted suicide’ , which had previously been unremittingly negative – a position that had, in turn, affected the willingness of politicians and the public alike to support various incarnations of assisted dying legislation. The review process, which concluded in 2016, included an online survey in which 3700 members participated. The conclusion? The AMA continues to oppose any legislation around assisted dying, but wants its members involved should such legislation come to pass.

A logical assumption from this is that the majority of AMA members, if not Australian doctors in toto, oppose voluntary assisted dying. But Neil Francis of Dying for Choice analysed the review process, in a fascinating report titled AMA Uncovered, in which he examines design flaws that encouraged desired responses, on the analysis of results, and on the way the survey was selectively publicized to justify the policy. The full report runs to 50 pages, but I’ve summarised what I see as the key aspects to take into account when assessing the AMA’s ‘revised’ position.

Doctors often underestimate the severity of patient symptoms but want significantly less medical end-of-life care for themselves. Nearly nine out of ten USA doctors would not want intensive end-of-life treatment they provide to others. Yet patient death, despite its inevitability, is often regarded by doctors as a ‘failure’ of medicine, with many still uneasy even about withholding and withdrawing life-preserving interventions. – p.15

There are three main areas to appreciate about the original report, as unpacked by Francis.

First, the data comes from an opt-in survey that captured just over 3,700 AMA-affiliated doctors; as the AMA represents just under 30% of Australian medical practitioners, respondents to the survey represent 12% of AMA membership, and only 3.6% of Australian doctors.

What the methodology variations suggest is deeply-entrenched hostility towards assisted dying that has flowed through to substantial biases is the survey design. These in turn will result in significantly more negative responses toward assisted dying in later questions than if the AMA’s policy had been revealed later in the questionnaire, after doctors had been asked their attitudes about various facets of assisted dying. – p. 21

Second, the survey is multiply flawed, a fact that was brought to the AMA Executive’s attention and dismissed. The most important of these flaws are briefly listed below:

the way questions are worded means responses are less likely to be genuine reflections of respondents’ beliefs and more likely to be weighted toward an anti-assisted dying response (see p. 16 of the critique for specific analysis)

the survey omits suffering or intolerable pain from its definition of euthanasia/assisted dying

the survey definition of euthanasia/assisted dying includes neither voluntariness or competence, both of which are key requirements

some established life-limiting practices (withholding/withdrawing treatment, the doctrine of double effect) are defined as separate to euthanasia/assisted dying

multiple questions presuppose a response in the framing of the question (e.g. “Do you agree…” or “To what extent do you agree…”

the first two questions separate ‘good medical practice’ and ‘clinically appropriate’ treatment when they’re dependent components of appropriate professional practice

similar, often successive, questions are differently constructed for no apparent reason

at least one question rolls two aspects of euthanasia/assisted dying together: being compelled to participate in the practice and (if unwilling) being compelled to refer a patient to another practitioner

Many Australian doctors don’t believe that the law is as important as medical and family consensus when making such decisions, and are inclined to ignore the law anyhow. – p. 19

Finally, and worryingly, it seems as though much of the opposition to or concern about this legislation is that a sizeable proportion of doctors don’t want this practice legalized. From the report, Francis notes that:

complementary research demonstrates 25% of Aus MDs support E/AD but don’t want it regulated/performed with oversight!

a significant proportion of doctors already deliberately assist patients to die, with neither protection of law nor, necessarily, patient consent

In a 2006 study “25% doctors were not opposed to euthanasia itself yet were opposed to its legalisation. In other words, a quarter of doctors thought ‘private’ euthanasia practice acceptable, but didn’t want the practice legalised.” The researchers said this was “in significant part due to ‘the resistance of doctors to further intrusion by the law and bureaucracy on their clinical and professional autonomy.’” – p. 25

I leave you with this observation by Francis, which should be particularly alarming for all of us (including opponents to voluntary assisted dying) who champion voluntariness, competence, and consent:

There were a couple of issues – first of all, Ms. Sales repeatedly refers to voluntary assisted suicide as “euthanasia;” the legislation soon to be introduced to parliament does not, except in exceptional circumstances, require or even allow physicians to administer the medication.

Second, the statistic of less than half of doctors supporting it comes from the AMA, which represents around 30% of Australian doctors, not even a majority of them. That said, I strongly suspect approval rates of assisted dying are very much lower in this group than in the general population.

I agree with Dr. Kaminsky that her “profession very much places an emphasis on ‘death equals failure,’ because our whole edict is to cure, to save life” – I’ve witnessed first-hand the distressing effects on patients, family members, nurses, and doctors themselves when they can’t accept the inevitability of death. It’s often said that doctors cure and nurses care, which I think does a disservice to to both our professions, and the impact of this inaccurate, divisive binary is worse for my medical colleagues. Doctors care, too, and they have an important role to play at the end of life, as is evident by the specialties of gerontology, general practice, and palliative care.

The problem is that Dr. Kaminsky is not distinguishing here between people who could be cured but aren’t being treated, and people who are inexorably, imminently, irreversibly approaching death – there is no saving available for them, only prolonging. And this ethos places the doctor at the centre of the situation, not the patient.

I wholly agree with Dr. Gold, with whom I’ve previously worked, that deliberately causing someone’s death would feel very uncomfortable. Even providing the means for a patient to do so themselves, even when they themselves have assessed that the person is choosing this, is competent, is dying, and is suffering, I do not imagine it will be easy. That in itself is one of the strongest, least slippery safeguards we have – doctors, like nurses, did not enter their profession to bring death, even to willing, eligible, pleading people; they study and work to make peoples’ lives better. It’s what ensures that applicants in Oregon are more often directed to other measures, including better palliative care interventions, than are prescribed medication to help them die.

Justine Martin, the multiply-unfortunate woman with MS, CLL, and SLL, articulates the desires of many people who have seen loved ones die badly: “I don’t want to end my life at the moment, but I want to know that if and when the time comes, that I will definitely have a choice.”

I agree with Michelle when she says that assisted dying can only be a real choice if excellent, expert palliative care is available. In addition to the Andrews’ government’s palliative care plan announced in 2016, palliative care services (from funding and resources to education and access) improve when assisted dying legislation is introduced, for that very reason – patients are better and more comprehensively assessed, and alternatives to assisted dying explored, including additional refersals to specialists and services.

And she’s right that coercion presents a genuine risk of influencing decision-making – which is why, as Dr. Carr points out, this legislation provides more safeguards for the vulnerable that they currently have. Assessing applicants, ensuring their requests are genuine, consistent, and uncoerced, will be a major part of the coordinator and consultant roles for doctors under the legislation, and of the legislation doctors will be mandated to undertake before playing any part in the process.

I fear that Dr. Kaminsky has not reviewed the advisory panel’s final report, because the concerns she raises are comprehensively addressed, from up-skilling doctors (a contributing factor in the 18-month period between the Bill passing both houses, and the Act going into effect), to how the medication is to be stored and who is responsible for returning it to the dispensing pharmacist if unused. There is more danger of unused narcotics “falling into the hands of a child” than a bitter liquid in a locked metal box, particularly as MS Contin and OxyContin are small and brightly coloured, Fentanyl patches can look like stickers or bandaids, and morphine mixture is sweet.

This is not an easy or straightforward issue. It shouldn’t be – it’s too nuanced, too important, and too open to misuse and error if not rigorously and robustly constructed. The Bill proposed in Victoria is tighter than any anywhere else in the world, incorporating the safeguards used in North America and Europe, in addition to measures unique to this legislation.

23/8/17 09:40 Edited to add: in a brief exchange on Twitter, Leah Kaminsky reported that she’d been quoted out of context, and has written a book about the realities of facing death; I have a copy on my teetering To Be Read pile – it looks particularly light-hearted and reassuring, given the subject matter, so I was a little surprised.The ABC has a second item about the positions of the same three Victorian doctors, for those who are interested in a little more on this: http://www.abc.net.au/news/2017-08-21/doctors-divided-over-voluntary-assisted-dying-legislation/8827204

Three days ago Nick Staikos, the MP for Bentleigh, tweeted about a leaflet his constituents had received – at first glance it could be construed as coming from his office, rather than from Right to Life, and Mr. Staikos did not appreciate the confusion.

This will be a conscience vote, which means each parliamentarian will decide for themselves, ideally based on review of the facts, and reflection on the best interests of the people of Victoria. The seat of Bentleigh is one of a small handful of very marginal seats – over a month ago, the Australian Christian Lobby announced that it would be targeting these seats, and “vowed to derail the legislation and electorally punish MPs who end up supporting it”.

I have no problem with lobbying – those of us who want this legislation passed will also be calling on like-minded people to contact their MPs, will (as I have) write to papers and post things on social media. The key difference, as I see it, is that while the people I’m talking with are very careful to remain accurate, calm, and support our positions with facts, those who think differently appear to be a little less cavalier with the truth.

I was given a pamphlet that, as far as I can tell, differs from the one distributed in Mr. Staikos’s electorate only by the MP details. Let’s take a look at it.

I’ll set aside the fact that Right to Life have created a false binary (in which suicide prevention is antithetical to assisted dying) and note that, not only is this intentionally inflammatory, it falsely conflates suicide (the intentional ending of one’s viable life) with the inevitable death of a person in the end stages of a fatal disease, illness, or condition – in the case of the former, intervention can result in a healthy, happy life; in the latter, the only question is whether the end will be comfortable and on their terms, or tormented.

First of all, the “government-sanctioned suicide” will not be by doctors – except in rare cases, where patients are unable to do so because of physical or digestive reasons, the role of doctors is to assess, advise, refer as appropriate, educate, and (if indicated by the screening process and the patient’s unwavering intent) prescribe. The use of the phrase “sick and inform” is hard to read as anything but intentionally misleading – anyone accessing this legislation must be nearing or at the end of life, from a disease, illness, or condition, and have suffering that not able to be adequately managed, aand be competent, unwavering, and uncoerced.

The question “Is he trying to save healthcare dollars?” is an egregious allegation. While it’s true that people on average consume (for lack of a better word) more health resources in the last twelve months of life than at any other time, that is rarely because of palliative care; far more often it’s because death is fought, with ICU, investigations, expensive imaging, and surgery. I have spoken with doctors, Victoria’s Health Minister, other MP’s, palliative care and hospital administrators, and not once have any of these people mentioned money. More than that, I have cared for patients for over a quarter of a century, in Victoria’s public system; despite the pressure for beds, and KPI’s, and review meetings regarding length of stay, nobody has ever suggested cost as a reason for transferring a patient or changing their care. If the Premier were motivated by that, a) surely he would have brought this up as an option earlier, either pre-election or when he was health minister, and b) his position wouldn’t have changed following his witnessing the dying of his father.

Right to Life end the facing page with equal distortion. We already have world class patient care, improving palliative care resources, and nobody is killing other people. The line “the life you save may be your own” is ridiculous – even in Belgium, where some of the most liberal laws are in place, people are not at risk of being killed against their will. Oregon’s laws are unchanged in two decades, and Victoria’s Bill is even firmer – this is nothing but fearmongery.

Onwards.

Apparently Right to Life are unaware that Britain comprises England, Scotland, and Wales…

It is true that, over time, utilization of these laws increases – as is the case with anything novel, from smart phones to laparoscopic surgery:

“If you legalize on the broad basis (that) the Dutch have, then this increase is what you would expect,” said Penney Lewis, co-director of the Centre of Medical Law and Ethics at King’s College London. “Doctors become more confident in practicing euthanasia and more patients will start asking for it,” she said. “Without a more restrictive system, like what you have in Oregon, you will naturally see an increase.” (source)

In the Netherlands, that increase is from 1.7% of all deaths in 1990 (before the introduction of legislation) to 4.5% in 2015; in Belgium

It is also true that both the Netherlands and Belgium have widened the parameters under which assisted dying may be provided, and that a person who has unbearable suffering without realistic likelihood of improvement meets the criteria, even if that suffering is psychological rather than physical. In the table below, “Underlying illnesses of Dutch assisted dying cases (proportion of all deaths)” (source), those patients are represented in bright blue, and account for some 3% of all assisted deaths in 2015. Cancer, which is the cause of almost a third of all deaths in the Netherlands, also accounts for the overwhelming majority of assisted deaths.

It is utterly untrue that the Oregonian law allows people accessed to assisted dying because they have a mental illness. A person must be:

1) 18 years of age or older,
2) a resident of Oregon,
3) capable of making and communicating health care decisions for him/herself, and
4) diagnosed with a terminal illness that will lead to death within six (6) months. (emphasis added, source).

Absolutely nothing there about mental illness being a reason to access the Act though, as here, having or having had a mental illness does not prevent someone applying, provided they are clinically competent.

Ms. Tighe’s pamphlet also refers to 431 people in the Netherlands whose lives were ended without specific request, and that appears to be accurate – on CBS’s statistical summary dated May 24 of this year, the breakdown of 7, 254 assisted deaths (of a total of 147,134 for the year) includes 431 titled “Levensbeëindigend hand. zonder verzoek” (or ‘assisted, end-of-life, without request’). That’s 0.059% of the 4.9% of Dutch deaths that are assisted, and that figure doesn’t tell us anything about the cases, or prior directives, and as 350 of those cases were patients aged 65 and over (201 of which were over 80), it is fair to assume many involved end-stage dementia.

This is certainly not ideal, but it’s also not applicable to the Victorian situation, where competency is an integral component of the process. It’s a pleasant to change to find a verifiable, accurate fact in this pamphlet, albeit one I suspect is also the worst Ms. Tighe’s organisation was able to find.

Speaking of verifiable facts, when we turn the page we find three cautionary cases from Oregon of women who were either forced into this option, or avoided it and lived happy lives.

As there are no citations, I have had to search for these stories myself.

Ms. Wagner’s case was publicised in 2008 when, after several years of treatment with first and second line chemotherapy, her insurance company refused to pay for an experimental drug that would potentially extend her life from four to six months, as Tarceva did not meet their requirement of 5% survival at 5 years. Indeed, at the time the drug made no significant improvement for 92% of patients, though it did induce rashes, diarrhea, and other unpleasant side effects in 19% of people taking it. Instead they were only prepared to cover palliative and comfort care, which included (but was not restricted to) assisted dying. After the media storm, the drug manufacturer agreed to cover the futile treatment; there are reports that Ms, Wagner died shortly thereafter.

Ms. Packer lives in California, and was anti-assisted dying well before any discussion about treatment funding. She was diagnosed with scleroderma, an autoimmune disease that causes scarring of body tissues, which was treated with chemotherapy; after three years, she entered negotiations with her insurer who, after five months, agreed to cover an alternative treatment, then changed their mind.

Packer then called her insurance company to find out why it wasn’t covered, and in none of the articles, Packer actually tells us why. You’d think that information would be useful in a news article about coverage denial. Instead, while on the phone with her insurer, she asked them if they cover the assisted suicide drugs and they said yes. The insurance company did not “offer to pay for her to kill herself.” (source)

Even if these cases had happened as described, they would not be reason to vote against the Victorian bill – Australia has universal health coverage, the overwhelming majority of people who need end-stage support use public facilities, and our private health insurance is voluntary, and paid by individuals – any company that instituted an policy that disallowed proven treatments with genuine outcomes would be abandoned by members in droves.

Death With Dignity have discussions about these and similar cases presented by groups like Right to Life, though Elizabeth Hall is not one of them. Google searches for “Elizabeth Hall” + “bowel cancer” + “assisted dying” came up with no relevant hits, and searches substituting “assisted suicide” and then “euthanasia” were similarly fruitless. There are insufficient details related on the pamphlet to know if the mysterious Ms. Hall would have met Oregon’s requirement of a six-month (or less) prognosis, but the number of people with end-stage bowel cancer who survive more than five years (let alone 15+) is very low.

What’s my take home message about these pamphlets? They certainly don’t seem to be created with education in mind, or even an argument against assisted dying based on any kind of coherent platform. Instead they have been written to heighten fear and apprehension, with deliberate skewing of the facts, and omission of vital information. If your argument can’t stand in the light, if it must be cloaked in emotion and distortion, then it isn’t robust, it isn’t valid, and it isn’t worth listening to.

One of the objections about assisted dying legislation is that vulnerable people will die, through coercion, because they feel like a burden on their families, for financial gain, or because their care is expensive or onerous. These are valid concerns to have – we know that there are unscrupulous people who take advantage of even their own relatives, that not all health practitioners are wholly ethical, and that there are financial pressures on health facilities at every level. And many of us have heard reports from overseas about people who didn’t meet the criteria being killed under the auspices of assisted dying laws, or weren’t reported to the government. While on closer examination these reports invariably turn out to be distortions or unsubstantiated allegations, a topic I may address at another time, the fear they address is a reasonable one – even if they haven’t happened, they could.

Last week, when I briefly summarised the final report of the voluntary assisted dying expert advisory panel, I mentioned some of the 68 safeguards that are in place. Today I’ll go into detail about the requirements and regulations that will be implemented to prevent this legislation being misused.

The first six safeguards ensure that requesters meet all of these threshold requirements before the process starts. They must:
• be eighteen or older (this law will not apply to minors),
• be resident in Victoria (people can’t travel here to die with assistance),
• be competent to make significant medical decisions (using the same standard the Medical Treatment Act, 2016, requires),
• have a life-limiting condition, illness, or disease (e.g. metastatic cancer, end-stage heart failure, motor neurone disease),
• have a prognosis of twelve months or less (their death is inevitable, and not distant), and
• be ‘experiencing enduring and unbearable suffering that cannot be relieved in a manner the person deems tolerable’ (e.g. for that person it may not be acceptable that the only analgesic dose sufficient to make their pain bearable makes them unconscious),

Note that a person must meet all of these criteria before the process of assessment can begin; in contrast, in the US people do not need to be suffering, while in Europe it isn’t required that they be dying.

The legislation specifically notes that disabilities and mental ill-health are neither barriers to, nor reasons for, voluntary assisted dying. In other words, someone may not access assisted dying because they have, for example, significant cerebral palsy, or are paraplegic, or have clinical depression, or schizophrenia – the requirements for a life-limiting illness, condition, or disease, a terminal prognosis of under a year, and enduring suffering, apply universally. Conversely, people who meet all the other criteria cannot be deemed ineligible because of a physical disability or mental ill-health.

The rest of the safeguards are divided into areas of protection. First are measures to ensure that the request process is voluntary:
• health practitioners are prohibited from bringing up the option of assisted dying with their patients – it must come from them,
• nobody except the person can request on their behalf, even someone with medical power of attorney and an advanced directive demonstrating that this is what they want,
• there must be three requests, over at least ten days, one of which must be written, and witnessed by an independent person, and
• the person can change their mind at any time, including after the prescription has been filled.

Next is the process of assessment, which is clearly and tightly described:
• two independent, experienced medical practitioners must separately assess the person (overseas this typically takes 60-90 minutes per consultation),
• only doctors who have undertaken specialized VAD training may be involved,
• the two assessing doctors are designated the coordinating practitioner and the consulting practitioner, each with well-defined duties, and
• either doctor may, and is obliged to, refer the patient to a mental health professional if they have concerns about the person’s decision-making capacity,

There have been concerns about prescribed medication going missing or being taken accidentally. To that end, the following measures will be introduced:
• the prescribing doctor must have a specific permit,
• the patient must nominate a contact person who agrees to take responsibility for returning the medication to the dispensing pharmacist if it is unused,
• from the time it is dispensed until it is taken or returned, the clearly labelled medication must be stored in a locked box,
• if the patient is unable to self-administer (e.g. is unable to swallow, has restricted arm movement), the coordinating doctor (and only the coordinating doctor) may administer the medication, and
• in that case the doctor must have additional certification, and the administration must be witnessed by someone who is independent of the doctor.

Unsurprisingly, health professionals, particularly doctors and nurses, have concerns about their roles, from being forced to perform acts with which they object, to being prosecuted. To protect them,
• health practitioners may conscientiously object to participating,
• there are protections for health practitioners who are present at the time of administration, and
• health practitioners will be required to report any practitioner acting outside the legislation.

There was a question raised about criminal consequences for health professionals who act outside the scope of the legislation – initiating a discussion about the option of assisted dying, for example. That is not specifically addressed, as there are already consequences for health practitioners who break the law or otherwise act in breach of the standards of each registered profession (one of which includes following the law), and charges of manslaughter and murder are not affected by the introduction of voluntary assisted dying legislation – it is still a crime to aid or to abet a suicide, or bring about someone’s death, except for the carefully delineated circumstances surrounding this Act. There will, however, be new laws introduced: failing to report any step, inducing or influencing a person to request or participate in assisted dying, and falsifying reports to the oversight and review panel will be criminal offences.

Finally, there have been allegations that not all deaths overseas that take place under the auspices of an assisted dying framework are reported or investigated appropriately. In Victoria, part of the process includes the creation of an independent multidisciplinary oversight and review panel. They are notified at every step of the process, from the first formal request to notification of death. Included in this process is notification whenever a prescription written to assist dying is filled. The patient’s contact person is tasked with returning the medication when the patient dies, if it was not used; if they fail to do so, the panel is empowered to follow up with them about the location of the medication, and ensure it is safely accounted for.

The oversight and review panel’s role will be enshrined in legislation, and it will have the capacity to refer breaches of the legislation to the appropriate authorities, from the health regulator AHPRA to the police. The panel will review every case, transparently report publicly, and publish a review after five years.

The expert advisory panel estimates that it will take eighteen months to set up all of the required safeguards (e.g. medical education) and legislative changes, before the first requests can be made.

But first the Bill has to get through both Houses of parliament. Which is where you can come in: if you support the legislation and you live in Victoria, please contact your lower and upper house MP’s to let them know – they can’t represent their constituents if they don’t know what you want.

Over the next couple of weeks I’ll explore some aspects of this comprehensive, 257 page report in greater detail, including one post dedicated to detailing and discussing the 68 safeguards it recommends. Today, though, I’ll just cover the highlights of the final report from an expert committee that comprised representatives from medicine, nursing, health care institutions, the law, disability advocacy, and palliative care.

The biggest take away message is that this will be the most rigid assisted dying legislation passed anywhere, taking all the requirements, oversights, and safeguards used around the world, then adding more.

To start, applicants must meet all of the following requirements:

be aged 18 or over

be resident in Victoria

be competent to make complex medical decisions*

be diagnosed with a terminal/life-limiting illness, disease, or condition

have a prognosis of twelve months or less, and

have suffering that is not able to be relieved

Each element is detailed, from who can initiate discussions about assisted dying (only the patient) to the requirements of the two assessing doctors (one of whom must be qualified in the relevant specialty [e.g. oncology, if the person has metastatic cancer], one of whom must have at least five years’ post Fellowship experience, and both of whom must be fellows of a college, and both must have completed the required VAD training); from the timing and sequences of steps (three separate requests, on in writing, over a period of not less than ten days**) to when a person can change their mind (any time in the process up to and including the point of swallowing the medication); safe keeping of the medication, from a designated contact person who must return dispensed medication if not used, to storage of the drug in a locked box; and oversight, from tracking presented prescriptions to review of all cases by an expert panel, who are reported to at each step of the way.

There are safeguards to ensure that unscrupulous relatives aren’t taking advantage of a vulnerable relative, with requirements both regarding competency (as mentioned earlier), and that witnesses to the person’s written request may not benefit from the person’s death. Similarly, in the event that physician-assistance is required (in rare case where the person either cannot physically pour, hold, and swallow the medication, or lacks the digestive process to safely swallow and absorb the usual oral preparation), there must be a witness independent from the assisting physician, to attest that the patient was willing right to the end.

The most significant aspect, consistent throughout, is that participating is voluntary for every person, at every stage. The requests must be made by the dying person; the assessing doctors have the right to conscientiously object; the nominated contact person must agree to taking responsibility for the medication and other obligations; nurses can choose to conscientiously object to involvement in education or facilitation of the assisted dying; and in the event that the patient needs physician assistance because they are unable to take the medication (either because of physical or digestive incapacity), the coordinating doctor must consent, along with the witness.

This is a rigorous, restrictive, robust document that provides consistent, thorough safeguards, strong review processes, and (in combination with registration requirements from the boards overseeing health professionals) penalties for breaches from and non-compliance with the regulations. Now we just need to get it passed.

* “The Panel considers that the four part decision-making capacity test in the Medical Treatment Planning and Decisions Act should be used to assess an adult’s decision-making capacity in relation to voluntary assisted dying. The Act is contemporary, having been passed in 2016, and is generally regarded as a appropriate to test decision-making capacity for a wide range of medical treatment decisions.” Ministerial Advisory Panel on Voluntary Assisted Dying Final Report, 2017 p. 60

** except in exceptional circumstances, when the person is highly likely to die within the usual waiting period

In 2013 I marched, for the first time, under the banner of my union, in Melbourne’s annual Pride march, honouring and celebrating lesbian, gay, bisexual, transgender, transsexual, intersex and asexual (LGBTQIA) members of our communities. I marched for my patients, colleagues, friends, and lovers who belong to these communities, and for those whose friends and families don’t or won’t support them.

I found marching a unifying, affirming act, and a public declaration of something I hold dear – the ongoing fight by unions for the rights and equity of marginalised groups: the right to be treated fairly, without bias or discrimination, without stigma or prejudice. That’s core union business, as much as fighting for women, for migrants, for 457-visa holders to have equal pay, rights and access.

And, I must confess, I found it gratifying to hear calls of “Here come the nurses!” “And midwives!” accompanied by cheers. It also felt good to be marching for something, in celebration, rather than against yet another attack on wages, conditions, or on those of us with least.

So it was with considerable regret that, for family reasons, I had to be overseas during Pride, both last year and this. I thought of Pride when Sunday morning (AEST) rolled around, marching in spirit though my body was in Colorado. And I visited the ANMF (Vic branch)’s Facebook page to see their post about this year’s march.

I was a little disappointed to find, among the positive comments, a couple of posts from people who felt that
● “no workplace union should be out there marching for moral issues”
● this kind of celebration is “a bit difficult, it’s all a bit Daffyd The Only Gay In The Village, look at me look at me”.
● “perhaps members should be consulted” before staff and members marched under the union banner, because “this is still a very controversial issue”,
● “gay rights etc is not a work related issue as such,”
● “Are we going to march for every single minority out there??? Either we march for all or none” and
● we have higher priorities than supporting Pride, particularly “access to health services”

This post is not at all intended to attack people who feel this way; that’s not helpful. Instead I’m writing this post to address the issues raised by these commenters – I don’t know if they’re members, but I’m certain there are members of our union who have similar positions. As I read it these concerns come down to:
1. there is something controversial about LGTQIA rights, or campaigning for them, or about LGBTQIA people
2. members should be consulted before ANMF endorses, supports or champions something controversial
3. union business is about work related issues, and ‘gay rights’ aren’t work place concerns
4. LGBTQIA people are a minority, and if we support one minority group we should support them all
5. there are more important things to fight for

First of all, I agree (as one of them went on to say) that “Gays should be accepted as just normal people with a different sexual preference, not as a race apart” though I’d word the sentiment differently. Unfortunately, though, that’s not yet where we are, and until sexual orientation and gender identity are treated as neutrally as eye colour or arm length, there’s work to be done. I’d like to take you through some of the other concerns that were raised.

Controversy and morality
It’s true that there is controversy in some segments of Australia about any kind of ‘lifestyle’ that isn’t heteronormative (one man and one woman, in a monogamous, preferrably married, relationship) and cisgendered (people whose identity, body, and gender assigned at birth are all the same). It’s hard to know from what was posted which aspects of LGBTQIA people the commentators have an issue with – I suspect, from discussions I’ve had previously about this, that there are a few, wrapped up together.

The first is that LGBTQIA people have wilfully chosen their orientation and/or identity to be difficult, controversial or subversive. To which I say: talk to the very many survivors who spent in some cases decades hating themselves, harming themselves, and planning suicide because of truths about their core identitites that they couldn’t change, however hard they tried. One of my friends sent me his story yesterday – for years the fear of being rejected by his family and the small town he grew up in cast such a deep shadow over his life that he was so deeply depressed he planned a one way trip, the only way Al could see to escape his “pain and torment.” It was chance and wonderous good luck that he was shown another path, to realisation of his potential, a man “full of fight and compassion and living a life of service, supporting and caring for others.” This is a reality for many people, especially young people, who feel different from the mainstream, and it’s not about who they are, it’s about not being accepted by those who should most love them.

The second, as illustrated by the Daffyd comment, is that marches like Pride are showboaty, prideful, and unnecessary. ‘Why,”some people wonder, ‘can’t they just get on with life like the rest of us?’ I would say for three reasons – the first is that, after years of hiding who you are, concealing key parts of who you are from family, friends, colleagues, community, there is joyous liberation in being able to say who you are, aloud, in public, and have it be celebrated. The second is to show young people, like my friend, who feel as though they’re alone, that there’s a wider world out there – that there are alternatives to spending your life pretending to be someone you’re not until the pain of hiding who you are is greater than the pain of claiming it, or ending the pain. And marches give people and organisations who support diversity, and the rights of all of us to live lives as full and productive as possible, to show that there are people and groups who’ll embrace them for who they are, without judgement.

The third is because they believe marriage ought to be reserved for straight couples (in some versions this is justified as being about rearing children). There is not space here to discuss this argument, as my response would double the length of this not short piece. What I’ll say instead is that the most recent survey of Australians’ positions of marriage equality shows 72%, or just under three-quarters of all Australians, support marriage equality.

Regardless of how one views the question of the morality of non-heteronormative, cis-gendered people, it’s true there’s still some controversy. Of course, I can’t think of anything that isn’t controversial – medical marijuana, asylum seekers, vaccinations, funding public health care, climate change – and for some of them debate will continue without resolution, however long we talk and whatever evidence comes in. ANMF (Vic) also has positions on all of these, any way. If we waited we’d never act on anything.

Consultation with members
ANMF (Vic) is a union, designed to act on behalf of its members – if we don’t, we’re no longer functioning as a representative body. We’re fortunate to be a very large union, with over 71,000 members at the time of writing, and individual consultation isn’t possible, so we have substitutes – work place representatives, who may choose to attend an annual delegates meeting, and elected officials. In addition, any member may make a submission to the union, directly, through their job rep, or through an organiser.

Last year, for example, I suggested we support the campaign to legalise medical marijuana – it’s a health issue, so if affects our patients, and it’s currently an industrial issue, as some members have become ensnared between the law and parents administering marijuana oil to hospitalised children, so it falls into our purview on two counts. And it’s controversial, because the majority of evidence is annecdotal, and it involves a drug that’s surrently illegal, which is why an email was sent to members asking for their response – fewer than 1,000 members replied, overwhelmingly positively, and so we’ve added our voice.

In 2012, at the Victorian branch’s annual delegates meeting, a motion was put that ANMF (Vic) support the campaign for marriage equality. The delegates present voted overwhelmingly in support the campaign for marriage equality. The members who moved, seconded, spoke to and voted for the motion are representatives of their workplace members. On this, the question of supporting equal rights for LGTQIA people, the members have already spoken.

What constitutes union business
Unions are about collective bargaining, improving work conditions (eg OH&S, pay and benefits, career structure), and equity, so supporting populations who are discriminated against is very much union business. Much of the progress made in work place gender equality, including equal pay and paid maternity leave, has come from the work of unions.

Perhaps, more than anything else, unions are about solidarity – about us being stronger together than we are separately, that united we have power and apacity to make change that doesn’t exist if we act alone. A key part of union solidarity is that we stand up for those who need their voices amplified. That’s why, at the last members meeting of our 2011/12 EBA campaign, Lisa Fitzpatrick told us about the NUW strike at Sigma Pharmaceuticals in Rowvill, and why some of us went along to support blue collar men and women whose work is nothing like ours, and whose fight was the same.

If we cared, and fought, only for those issues that we were directly affected by, there wouldn’t be a union movement – and so much of what we take for granted, the rights we have every day, wouldn’t exist. Why would men care about women being able to work after they were married? Or maternity leave provisions? Why would teachers care about deaths on construction sites? Why would Australian workers fight for the rights of workers in Sri Lanka? [link: http://www.sigtur.com/latest-stories/union-protest-embarrasses-ansell.html – photo, if we have one?]

Solidarity is why ANMF (Vic) staff and members marched alongside teachers, fire fighters, paramedics; why we’ve marched for asylum seekers, World Peace day, marriage equality, secure work, maintaining funding for WorkCover, and for Medicare funding. Because all of these things matter, and we are part of all of them – as my friend Benjamin says: “Solidarity means you march and support those groups who are still in many ways at the bottom of the pile socially, ecomomically, culturally and politically.”

However, even if that were not the case, this is also a health issue – stigma, persecution and discrimination are strong contributors to the high rate of depression, anxiety, suicidality and substance abuse among people who are LGBTQIA, and that makes it very much an ANMF issue. As does the fact that our members include lesbian, gay, bisexual, transgender, transsexual, queer, intersex and asexual nurses, midwives, patient attendants and students. Participating in this march shows people that it’s okay to acknowledge who you are, that you’re not alone (however much it may feel otherwise), and that you’re supported and accepted by the wider community.

And that, I hope, also addresses the question about whether we’re going to support other (or all) minority groups – if they’re discriminated against, if they have access to fewer rights, lesser conditions, then yes, we will.

What we should fight for

Late last year Victorian Trades Hall hosted a film night to thank volunteers involved in the election campaign. The film screened was Pride – it tells the true story of how a small group of London lesbian and gay men decided to support the 1984 Welsh miners’ strike:

It is a brilliant film that illustrates far more eloquently, ably and upliftingly than I just how LGBTQIA rights and union fights intersect, though the miners’ union took a year to come around to that position. Indeed, the fit is so natural, so apparently self-evident, that I was genuinely shocked it took until only thirty years ago to be embraced in the UK.

In Australia, though, some of us got there a little sooner – in 1973, five years before the first Sydney mardi gras, and 11 years before the events recounted in Pride, members of the Builders Labourers Federation working onsite at Macquarie University went on strike in support of a gay student activist who was excluded from the university because of his refusal to repress his orientation and “seek help.” I wrote about solidarity – it’s a core union value, and always has been.

It’s hard to think of many groups less likely to support a gay tertiary student than early seventies construction workers, but “It’s the principle of the thing. They shouldn’t pick on a bloke because of his sexuality.” – Bob Pringle, then-BLF President (NSW branch). Read more here) And they went out again, the next year, when Penny Short’s scholarship was withdrawn because being a lesbian made her “medically unfit.”

There are higher priorities
Finally, the concern was posted that LGBTQIA rights are outweighed by other, more direct concerns facing nurses and midwives, including cuts to health care funding, inadequated aged care services, and poorly served rural and remote communities. And it’s true that there is an increasing demand for health care services, and Mr Abbott’s attacks on Medicare certainly warrant a strong and decisive defence.

I won’t ask if the person who posted this comment fought against the privatisation of Victoria’s public aged care beds, or has campaigned to save Medicare, though I’d like to note that I have, and I’ve been proud to stand shoulder to shoulder with my union’s executive and staff while doing so. Instead I’ll point out these two things. First, like sexuality, this isn’t a binary state – we can champion more than one injustice or cause at a time. Indeed, we must – if we only focused on one issue, however worthy, we would have trouble achieving anything. And for the second I will once again cite Benjamin:Being part of any group larger than just ourselves means there will be things we don’t completely agree with – compromises for an overall win, fighting on behalf of people who are happy to reap the rewards of a campaign without participating, or agreeing to step back on one point for an intact and united front. Nobody is asking anyone else to participate in, or to personally endorse, anything they don’t agree with, and though I am a member, a long-time job rep, and a new branch councillor, I don’t speak for ANMF – in this piece, on my blog, to the media or on social media.

That said, I know I speak for ANMF (Vic) branch, for ANMF federally, and for the union movement as a whole when I say – lesbian, gay, bisexual, transgender, transsexual, queer, intersex and asexual rights are human rights, and they are most definitely a union fight, a health issue, and ANMF business.

Note: I am indebted to those friends who responded to my request for comments as I was writing this, including my anonymous friend for allowing me to use his story, Benjamin for drawing my attention to the case of Jeremy Fisher and for permission to use his words, and to Julie Wearing-Smith for both her support and for encouraging me to expand a Facebook response into a rather lengthy essay. And while I’m at it, thank you to my wonderful union.

This post was prompted by being involved in two discussion threads about immunisation yesterday, one on FB and one on Twitter (the latter still progressing). They’re not the first, and I very much doubt they’ll be the last. I started writing this as a FB post, and when it grew, decided it would be better here – partly because of its length, partly because I wanted to insert a couple of sources, and partly because this way it may have a wider audience. If so, I hope it’s useful.

To eliminate any doubt, I am a proponent of vaccinations – I have the fluvax every winter (and the one year I didn’t, through chance not intent, I contracted H1N5), and I paid to have a pertussis vaccination because there are small children in my life. Even if I wasn’t concerned about the health and welfare of my father (who’s on immunosuppressant medications for an autoimmune disease, and who had an emergency splenectomy three years ago, so is double compromised), my infant nieces (born early and living in one of the lowest vaccination areas in the US), myself and my colleagues (daily exposed to infectious disease, sometimes undiagnosed on presentation), and my patients (transplant recipients, people with cancer, people with diabetes, people with autoimmune disease, people with HIV), I’m concerned about my community. As a tax payer I’m concerned about the massively higher cost of treating, rather than preventing, these diseases.

And as a nurse…It’s clear that many people who oppose vaccinations do so out of fear and concern for their children’s safety, and I understand how, if you haven’t seen these rare-but-returning diseases, the threat of some nebulous something bad happening that you facilitated feels more real than childhood illnesses like chicken pox that you had and survived intact. Vague theories about herd immunity, and protecting other people’s children feel a lot less important than the safety of the child in front of you – your child.

And a lot of the components sound alarming – until you realise that formaldehyde is also made by your body, and is present in far higher quantities in everyday foods, like apples and pears.

“But,”I’ve been told, “that’s naturally occurring formaldehyde, not synthetic.” In some cases that may make a difference – at a molecular level (and formaldehyde’s a molecule), a molecule’s a molecule.
Or that the foetal bovine serum is a growth medium for live culture, present at miniscule levels within the attenuated virus, and that insulin used to be manufactured from porcine and bovine sources. Or that insulin today contains “glycerol, phenol, meta-cresol, zinc chloride, dibasic sodium phosphate dihydrate, sodium chloride, sodium hydroxide, hydrochloric acid” but we don’t see people refusing insulin until they have proof it’s safe. (Here’s a FDA link explaining why vaccination components are needed).

While many of us would be ashamed or embarrassed being labelled illiterate, there’s sometimes a kind of pride in being innumerate (mathematically illiterate or sub-literate), and the same, perplexingly, goes for scientific illiteracy. We can’t all understand my astrophysicist brother-in-law’s research (I certainly don’t), but fundamental scientific knowledge should be, well, fundamental – like the fact that everything’s made up of chemicals, even natural, unadulterated, organic, raw food.

Chemicals are not, as a group, dangerous, scary, undesirable, or possible to avoid. Their names can be long and complex, but they’re part of everything around us, and they are us.

The people writing this skewed information have to know that, while its true a high salt diet causes hypertension in genetically prone adults, alarmingly listing ‘sodium chloride’ as a “Toxic vaccine”ingredient, with the described effect of “Raises blood pressure and inhibits muscle contraction and growth” when it’s present in a smaller amount than is in a handful of corn flakes, is at best misleading, and almost certainly false. They certainly know that vaccinations aren’t “injected directly into the blood stream,” too – as everyone who’s ever received any vaccination knows, they’re injected into muscle, in either the upper arm, thigh or (rarely) buttock.

If their evidence of risk is robust enough to mean parents shouldn’t immunise their children against the known and real risks of infectious diseases, why muddy the waters with clear distortion, mistruth and fearmongery?

It’s true that vaccinations are not without risk. They’re as safe as we can make them, but there will always be some risk to some people. When it comes to vaccinations, most of the adverse reactions are mild – redness or low-grade (treatable with paracetamol/acetaminophen) pain at the site, low-grade fever, a harmless rash – and considerably milder than the disease they’re protecting against.

In very rare cases a person may develop anaphylaxis, a life-threatening histological response that causes swelling of the airway – this occurs almost immediately, which is why there’s an observation period after receiving any vaccination, and why immunisers are trained in anaphylaxis management. The rate of anaphylaxis for the measles vaccine is 3.5-10/1,000,000. There are also risks of febrile convulsion* (generally one, with no ongoing problems) at a rate of 1 per 1,150-3,000, and possibly a rare blood disorder, thrombocytopenia (source for both stats as before).

For comparison, I wanted to provide the anaphylaxis risk of other agents, including peanuts, bee stings and ant bites, but though their incidence (and the incidence of other food allergies) is increasing, particularly in Australia and New Zealand, actual risk-per-exposure figures don’t seem to be easily sourced – te closest I found was this update from the Australasian Society of CLinical Immunology and Allergy. I suspect that’s because vaccinations are more highly scrutinised than other potential allergens; whatever the reason, though I can’t provide figures, there’s no question the reaction rates are higher for these hazards, by many times, than even the mildest response from vaccinations.

However, we already know that facts rarely sway people who have made decisions based in part, or in whole, from emotion, particularly fear. Indeed, facts can make them feel attacked, and more strongly hold on to their position. So the two-fold points of this post (at last!):

The first is for people who are concerned that the risks of vaccination outweigh the risks of preventable disease:
– why do you mistrust the opinions of the overwhelming number of experts?
– conversely, why do you place more faith in the opinions of people who have, on the face of it, less knowledge and fewer qualifications?
– what kind of evidence or argument would give you cause to reconsider?
– are you opposed to/concerned about all vaccinations, or some?
– if the latter, why them?

And for those of us in health, government and public policy:
– what strategies can we utilise to enhance listening and engage concerned parents?
– how can we more effectively educate the public about the risks of diseases, and the comparative safety of immunisation?

If you’re reading this and have an opinion, whether you fall into one of these groups (concerned or practitioner – or both!), please comment – I value information about this.

And on a far bigger level – we must, must, must increase numeracy, scientific literacy, and critical thinking across the board. People who understand the concepts underlying theories (including herd immunity and climate change), who can assess statistics, and who can detect invalid arguments and faulty premises, are better equipped to make informed decisions about all aspects of their lives, from taking out short-term, high interest loans (the topic of another rant) to deciding on vaccination.

*I had a febrile convulsion as an 18-month old, as the result of a nasty cold – children under the age of two have more trouble regulating high temperatures than adults do. I had no complications, and have never had another seizure.

The first time I heard Opposition Leader Daniel Andrews promise to maintain Victoria’s nurse/midwife-to-patient ratios was on December 9th, 2011, outside the new Royal Children’s Hospital. He said that he admired and respected the work that nurses and midwives do, that he knew how important ratios were, and that if he were Premier when we next went to negotiations, ratios wouldn’t be on the baragaining table.

It would be another four months of unprecedented action and governmental bad faith before then-Premier Baillieu and Health Minister Davis – after pushing distraught nurses to take strike action for the first time in a quarter of a century – finally agreed to independent arbitration, protecting the ratios ANMF (Vic. branch) Secretary Lisa Fitzpatrick rightly calls our profession’s first born child. And I heard Mr Andrews make that pledge two more times.

What convinced me that his commitment was sincere – for politicians make and break promises all the time – came six months after that summer day, at our delegates conference.After making that promise again, Mr Andrews invited questions from the floor, and was asked to commit to another improvement, outside the public acute sector.

His response was measured, and clear – he would consider it, in the event he was fortunate enough to be granted office, but he had not looked at what implementing that measure would involve, and he would not make uncosted promises.

That indicates integrity to me, an impression reinforced a few months ago, when a source inside the Labor party told me Mr Andrews’ determination to act as though his promises would always have to be carried through had not won him friends in the back rooms among members who thought he should promise whatever it took to win.

Today I was delighted to be present at ANMF House, when Daniel Andrews committed not only that, under a Labor government, we won’t have to fight to keep ratios as we have in 2001, 2004, 2007 and 2011/12, but he’ll enshrine them in law – you can see his speech here.

This is more significant than most nurses and midwives realise – earlier this year the High Court found that fire fighter ratios, though contained in their EBA, were not legally enforceable, which makes vulnerable every occupation that has staff and workload provisions – think not only our ratios but classroom sizes to get an inkling of the scope.

In addition, he followed through on his signature a few weeks ago of ANMF’s 10-point plan to combat violence with a $20 million pledge to increase hospital security and prevention measures.

There is clearly more that needs to be done, including in aged and community care, but this is a real and very promising start.

And why do I think that Mr Andrews will keep his promise?

Not only because no sane person wants to risk the ire of ANMF (Vic branch)’s 70,000-strong members, but because I believe Daniel Andrews has integrity, and that he genuinely understands, appreciated and respects the roles nurses and midwives play in the health care system.

Mine were not the only wet eyes in the room when Mr Andrews promised to respect ratios, and that he appreciated and honoured the work we do – he received two spontansous standing ovations from the ANMF members present, for good reason. This is more important to us than almost anyone outside the professions can appreciate.

The current government have left paramedics without an agreement 26 months after their EBA negotiations started – they haven’t had a pay increase since 2011, and Australia’s highest trained paramedics earn some $30,000 a year less than their WA colleagues. If elected, Mr Andrews will send their dispute to Fair Work as his first act as Premier.

There are many reasons I believe an Andrews-led Labor government will be best for nurses, midwives, the public, and our state. His commitment to health, and my belief in his fidelity to his priomises, is a part of why I’ll be voting for Labor in 31 days.**This post was written on October 28th, but not published until November 5th

The Abbott government was elected on a raft of lies and broken promises, all of which have the potential to have devastating consequences for many people, predominantly pretty much exclusively those with least to begin with. Not that it’s always easy to tell precisely what the effects are going to be, as even Mr Abbott’s Cabinet seem to be unsure, as evidenced by yesterday’s quick about-face on pursuing HECS debt after death (and The Conversation‘s retraction of how long HECS will take to pay off now course costs and interest will rise, but the payment threshold will drop).

I’ll write about some of the other ‘reforms’ being introduced next week, particularly the targeting of people on Disability Support Pensions. Like my topic for today, that tactic’s come straight from the UK Tory playbook.

In the UK the Conservative government slowly starved the NHS of funds, then turned around and said “see? It doesn’t work!” as an insidious privatising began.

Australia leaped ahead a little there – we’ve started selling off aged care facilities already, with barely a whisper of consultation, let alone publicity (and that, too, I’ll address next week). But today I want to talk about co-payments for GP visits (and allied health consultations, and radiology, and other investigations).

This government has launched a concerted attack on universal health care. It started with a rubbery statistic – that annually, we make an average of eleven GP visits a year. That sounds like a lot to most people, and when uttered hand-in-hand with insinuations and outright claims that ‘some people’ (predominantly over-anxious mums, and the isolated elderly) are going ‘too often’ makes it seem reasonable for a tokenistic disincentive to ease the strain on our struggling public system.

Only none of it was actually true. On average, Australians see a health care practitioner who bulk-bills all or a portion of the visit eleven times a year, true – GP’s comprise about half of that, with the remaining visits going to physiotherapists, occupational therapists, dieticians, speech pathologists, diabetes educators, clinical nurse practitioners, and the like.

There are undoubtedly some GP visits that are unnecessary – after the fact, because often it’s not possible to tell if the issue’s significant or not; laypeople aren’t doctors. And even if you know that what you’ve got doesn’t require medical attention, many visits are for mandatory medical certificates for time off work or school.

But, says Mr Abbott, we don’t value what we get for free – a small impost, the cost of a cup of coffee, a sandwich, a couple of middies, is enough to make malingerers stop, think, appreciate what they’re getting.

Only here’s the thing – we already pay for Medicare. There’s a specific levy for it. And while it’s true that the levy’s 1.5% (plus an additional 1% if, like me, when you earn over the threshold you choose to support universal health care instead of private insurers), and Medicare costs 9% of GDP, that’s been the case since 1997.

Oh, but Medicare’s unsustainable, and so we have to pay more toward it.

Except that (despite cutting CSIRO funding to the bone, including the agencies that take research from the lab to the market, where we can make money – an area where Australia lags sadly behind most countries) we need the money to fund an enormous medical research centre. Not now, but in the future, when the funding comes in. Because that means we won’t need to spend so much on health care…

Our health care system is robust, cost-effective, and it delivers. It’s not perfect, but its imperfections are predominantly in under-servicing rural and remote areas, under-funding aged care and mental health, inadequate preventative interventions, and too much emphasis on sexy, expensive, acute care.

Amazing NSW nurse Kerry Rodgers on QandA

Here’s the reality – if you want to cut health care costs, general practitioners are not the place to look. They are one of the most cost-effective parts of our system. Good GP’s save money, and lives – prompt action means that many acute issues can be treated before they worsen, and chronic conditions are managed before they become life-threatening.

We don’t have figures on how much a hospital bed costs per day, before medications and interventions (though we do for aged care),so I can’t say how much an outpatient treatment of cellulitis through a course of oral antibiotics compares to inpatient admission for five to seven days, with intravenous antibiotics. I can tell you that it’s easily a hundred times more, based on the cost of the drugs and administration alone.

I can tell you with certainty that giving pneumovax or Fluvax to someone at risk costs a fraction of treating them for pneumonia or the ‘flu – and that, having had both, you’re looking at weeks of time off work as well as direct health care costs. That’s bad from a productivity perspective, disastrous if you’re one of the 40% of our work force on casual or contract work.

Poorly controlled diabetes causes multiple irreversible complications that mean anything from admissions for amputation, to dialysis – we know that the best, and least expensive, way to avoid that is regular education, supervision and support, including annual eye exams, bi-annual podiatry, lab bloods, and consultations with a specialist team of endocrinologists, dieticians and diabetes educators working with the client, family and GP.

That’s just three conditions, off the top of my head. As a nation, GPs are cost-effective. For those who are already struggling to make ends meet, Mr Abbott’s ‘small impost’, Ms Bishop’s sandwich, Mr Hockey’s middies or a third of a packet of smokes is the worst kind of disincentive.

These are people who’ve never had to decide between utilities and rent; between school shoes or dinner; who’ve never wept at a parking fine or rent increase. If you’ve never felt your heart leap at the discovery of $5, if a bought sandwich is an everyday occurrence and not a rare treat, you don’t get to decide that $7 isn’t much.

We know what will happen as a result of this move: those who most need early intervention will delay seeing a doctor, and present at emergency departments far sicker than they need to be, which means more cost for the system, and a lot more pain, suffering, risk, and potential economic consequences for them and their families.

Those who are on disability or aged pensions and have multiple medications will reduce their doses to eke out their drugs; fewer infants and children will be immunised; Pap smear and prostate exams will fall; annual wellness checks will be skipped.

And in the short term there won’t be an effect. But it won’t take long – and I mean months – before we start seeing the real damage, in human and fiscal costs.

We know this is a government that creates policies of myopia, that is incapable of long-term or big picture thinking. And we know that it’s a lot harder to reinstate a service or good than it is to retain it in the first place.

The time to act is now. Let your MP know that you don’t support co-payments. Write to the media, ring call back radio, tweet and post and shout it.

And if you’re in Melbourne, and you’re reading this today, join thousands of health care professionals and concerned citizens as we march for Medicare!

In every developed country, the nursing workforce is aging – in Australia, over half of all nurses are aged 45 or older, and there’s a predicted critical shortfall less than a decade away.

Although this is well known, our government is not addressing the issue – though more students are being accepted into nursing degree programs (including Masters-level courses for applicants with an undergraduate degree in another discipline), funding for an intern-like graduate year has been slashed. This is a national problem, but Victoria has the highest number of placement shortfalls – last year over 800 graduates were left without a program placement (something I’ve touched on previously).

Like all degrees, nursing and midwifery are subsidised by the government – student fees only pay part of the course delivery cost. Yet, after investing tens of thousands of dollars in each graduate, the governments in every state are funding fewer graduate positions for nurses and midwives. Though not mandatory, without a graduate year it becomes increasingly difficult for inexperienced nurses to find even casual work, and it’s even harder for new midwives.

Instead of investing in local graduates, we’re filling shortfalls with 457 visa holders.

In the short-term, graduate year programs are expensive – newly-qualified nurses need supervision, including supernumerary time with a more experienced nurse, and have paid study days. Importing nurses who don’t need that investment looks economically advantageous.

And, though employment conditions are the same regardless of origin, nurses on 457 visas are less likely to know their rights and entitlements, or to take action if those rights and entitlements are curtailed – in all industries there are cases of 457 visa holders being under-paid, assigned longer hours, heavier work loads, and less leave time than they’re entitled to. There’s valid concern that any kind of protest, or even query, will see their visa revoked.

Failing to invest in our own graduates harms our profession, and our public. We cannot staff our hospitals solely with experienced local nurses supplemented by overseas-trained nurses – there aren’t enough, for a start. There will be decreasing incentive for students to study nursing or midwifery in Australia if they know that the odds of them then being able to work are lower every year. And without the equivalent of three months of full-time work, they’re ineligible to re-register, meaning every year Australia is losing hundreds of the next generation of nurses and dozens of midwives – nurses and midwives whose education we’ve already paid for.

We all benefit from the experience and perspectives of nurses and midwives from overseas, and many Australian nurses spend a few years overseas, particularly in the UK; reciprocity’s fair.

457 visas are appropriate when there’s no local skill; when it comes to nursing, midwifery, and many other industries, we have the people – we just don’t have a government prepared to invest in them.